1. WHY WON’T THIS VENOUS ULCER HEAL? Noel Parent MD, FACS, RVT SENTARA VASCULAR SPECIALISTS Virginia Beach, VA

2. Variety of leg ulcer etiology  Decubitis (pressure)  at points of contact  Ischemic (arterial)  malperfusion  Infectious  Foreign body  Rheumatologic or autoimmune  Venous  Venous hypertension

3. Venous ulcer characteristics  Ulcer location is medial lower calf just above the ankle  Hemosiderin deposition  Lipodermatosclerosis  Edema  Size variable  Varicose veins +/-

4. It all begins with loss of venous valve function (venous reflux)

5. Importance of the perforating veins

6. Elevated pressure within the veins of the calf skin is the pathophysiology

7. How to decrease venous pressure?

8. Traditional surgical treatment

9. Why vein ulcers…  …did not heal in the past:  INADEQUATE DIAGNOSTIC IMAGING  IMPRECISE INVASIVE TREATMENTS  …why they may heal now:  DUPLEX ULTRASOUND IMAGING FOR VEIN MAPPING  EVLT IS PRECISE AND MINIMALLY INVASIVE

10. Duplex ultrasound perforator vein imaging to access for ablation

11. Percutaneous fiberoptic laser delivery of thermal energy

12. SVS Vein Center of Virginia

13. Perforator vein identified by duplex scan

14. Perforator vein cannulation

15. Insertion of laser fiberoptic

16. Tumescence anesthesia

17. Ablation of perforator vein

18. Case example #1  Very dirty ankle venous ulcer in an elderly female.  Complex PVL showing: chronic thrombus in GSV. Note associated SSV reflux and two incompetent calf perforator veins.

19. Case example #1, cont’d  PVL confirms successful ablation of GSV, SSA and perforators.  6 weeks post endovenous laser treatment: ulcer healing for the FIRST TIME IN A YEAR!

20. Case example #2  Pre treatment  Post treatment

21. Retrospective study of EVLT for venous ulcers in SVS/VCV

22. Compared 3 groups of patients

23. Incidence of ulcer healing

24. Improvement in VCSS

25. Minimal complications

26. Summary  Leg ulcers are commonly due to elevated venous pressure in skin from valve weakness resulting in reflux.  Results from traditional therapies of Unna boots, stockings, and open surgery are disappointing. (Costly, morbid, disabling)  A contemporary treatment consisting of duplex scan diagnosis of perforating veins, then treatment by EVLT, may become the new standard of care.

27. The End – thank you